Up the ACA Creek -- With a Paddle

On November 23, it was announced that eight more days than originally required would be granted to those shopping for health insurance to "review plan options, talk with your families ... and enroll in a plan." So now you've got until December 23 to sign up for health insurance.

Maybe you thought, "Well, the website's supposed to be fixed, so I'll just go online." Or maybe you plan to do it over the phone or with a "healthcare navigator." No matter what, there are some things you need to know and questions you'll need to ask as you navigate this creek.

Medicaid

If you live in a state where Medicaid has been expanded, chances are the process of signing up will be much simpler and easier than for those who don't qualify, don't have insurance already, or have to go to the insurance exchange. Mostly, it will be a matter of whether you qualify based on your age, where you live, and financial situation -- there will be forms to fill out (there always are), but it's pretty straightforward. You qualify if you are:

younger than 65

live in a state that is expanding Medicaid

and make up to 133% of Federal Poverty Line (FPL), which would be $15,857 for an individual, including those without children.

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Insurance Exchanges

You can no longer be denied insurance because of a pre-existing condition, BUT, in preparation for speaking to someone about the various policies, be sure to have a complete list of the medications you're on and anything else that requires a prescription.

Ask specifically if all your medications are included on the formulary of each plan, especially the cheaper plans (see The "Fruit" of the ACA at http://bit.ly/1aSU95A).

Before you even make the first move, decide just what you're willing and able to give up. Are you willing (and able) to take multiple pills more than once a day if Atripla is not covered by the plan you want? Or is a one pill once-daily regimen necessary for you to remain adherent?

How much is really "affordable" for you? Can you make do with less food? Without cable TV? Without the latest iTunes download? Can you trade in your smartphone for a dumbphone?

In Illinois, a BlueCross Blue Shield PPO is estimated to cost $212.76 per month for Bronze, $293.81 for Silver, and $369.88 for Gold just for the premium. Humana is the only company offering Platinum plans and those would cost $476.03. Remember, this doesn't include deductible, co-pays, or co-insurance.

But you've heard that with the subsidies, premiums can be under $100! Here's the thing -- in order to qualify for a subsidy, you must make no more than 400% FPL. Modified gross income (what you make on paper, not what you bring home) is the figure that's used to calculate it. According to information at healthcare.gov, 400% FPL would be $45,690 for an individual. If you make that or more, no subsidy. If you make between 133 and 400% FPL, your subsidy will be on a "sliding scale," with the biggest subsidies going to those most in need.

Costs

There are two categories of costs that you must pay: premiums and out-of-pocket costs (OPC). You will be solely responsible of out-of-pocket costs, which include your deductible (the amount you must pay for services before your insurance pays a cent), co-pays (the amount you pay every time you enter a doctor's office), and co-insurance (the amount that isn't covered by your insurance).

There are also two categories of savings -- subsidies apply only to premiums and "cost-sharing" (OPC) savings apply only to Silver plans, so even if a Bronze plan is cheaper premium-wise, you may have higher OPC than with a higher-premium Silver plan. Bottom line -- you're going to have to do some math and figure out if lower premiums are worth the higher OPC.

Things you must be clear on before you purchase a plan:

How much is your deductible? Remember that you have to pay that amount before your insurance pays anything. The deductible may not apply to some services, such as preventive screenings. Make sure you know what services the deductible will be applied to.

What is your co-insurance? Usually expressed in percentages, if you get a Bronze plan, the insurance company will only pay 60% of total costs for services, so that would mean you would pay 40%. Silver plans pay 70%, Gold 80%, Platinum 90%. No exchange insurance policy pays 100% of your costs.

Example: if you fall down and break your hip and the total cost of an ambulance ride, an ER visit, x-rays, hip replacement surgery, physical therapy, doctor visits, and drugs comes to $50,000, after you pay your $1500 deductible and your $150 ER co-pay, the bill would be $48,350. Your 40% would be $19,340. So your OPC for that fall would total $20,990. Your insurance would pay $29,010. So having Bronze level insurance would save you a whole $8020.

What is your co-pay for each doctor you see? If your HIV doc is your primary care physician (PCP), you should have to pay less to see him/her than you would if your PCP is a general internist who refers you to an HIV specialist, Specialists usually require higher co-pays.

Is your doctor(s) still in your network? Insurance companies are shrinking their networks in order to discourage high-risk patients who need specialists from choosing their plans. HIV docs are some of the ones being booted out, so that means you either find a plan that your favorite doctor is covered by or you risk lower quality care by a doctor who may know very little about the complexities of treating HIV. This is just one more way insurance companies control access to care while protecting their profits.

There is no way to simplify the navigation of getting insurance from the ACA exchanges, but just like with HIV, the more you know, the better off you'll be. There is one truth that's indisputable -- having insurance does not guarantee having access to care. Before you pay a cent, make sure you will have the care you need!

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